The apathetic patient with a bad skin ulcer

A middle aged man is brought in by ambulance to the ED with a report of diarrhea, a wound on his butt and low pulse. As soon as he is brought into his room and the nurse sees him, she comes to find me to say, "he doesn't look as bad as his numbers would make you think." And that would be? His blood pressure is 73/4o something. I take a look at him. The nurse takes a look at me, and like any good nurse, reads my mind and orders her assistants to move the patient immediately to our resuscitation bay.

While the crew is busy getting a second IV and attaching a cardiac monitor, I approach the bed an introduce myself. The patient is pale is a ghost and looks like he has been living in a cave. Turns out he had been. Almost.

"Who called the ambulance for you sir?"

"My VNA."

"Why's that?"

"She said I didn't look too well."

"Where have you been living?"

"In a shed behind my parent's home. It abandoned now that they're dead."

I see dried diarrhea down his legs, although strangely he doesn't smell that bad. Not at all like homeless-drunk bad.

"Where have you been going to the bathroom and what have you been eating?"

"I don't have a toilet no where and I've been eating some food my brother has been bringing me."

He is pleasant, and cordial in his answers. Not at all the combative and confused patient you would typically expect judging from his appearance. He is emaciated, poorly kept, long greasy hair. I don't know why, but a picture of an old hick from the backwoods of 19th century Kentucky diseased with hook worm comes to mind.

But what is even more odd is that he has a list of medicines with him. Many of my patients in far better social circumstances don't even know the name of the medications they've been on for years, or have the sense to carry a list in their wallet. And then he says, "but Coumadin is not on there, I'm taking that too." I can only guess how far off his Coumadin level must be. "And the name of my cardiologist is..." I'm floored. I guy living in a shed wallowing in his own crap actually has a cardiologist and can tell me his name????

Turns out he doesn't have any complaints really. But that blood pressure is still in the toilet, even after 2 liters of fluid. He's mentating perfected well. Really? Nothing's bothering you sir?

So then we go to turn him.

And on his tailbone is a dinner-plate size area of black, rotting flesh with a large gaping hole packed with fetid newspaper. "Got to explore the wound," I hesitantly mumble to myself. I glove up. I want two layers of gloves for this one. No, maybe three. I want a face shield, a gown. No, just give me a hazmat suit. I nervously pull out pieces of the newspaper, unsure of what I will find. It's stuffed in there deep. I mean real deep. Down to the bone, an ulcer large enough to stick in a large grapefruit. And then I see a maggot. I stop and look up at the nurse. She is mortified but maintains composure. The smell is beyond description and I nearly vomit all over the bed. I step away and ask for an instrument kit with some forceps and the overhead surgical light to be turned on. By this time word has got around the department and my colleagues are filing in one by one to gawk with morbid curiosity. I return to the matter at hand and what I see is utterly foul. There is a mass of frantically wriggling maggots trying to escape my detection by burrowing themselves into deep recesses of the ulcer. I pluck a few out and rinse the ulcer with water.

No, strangely, this does not hurt he says. He has no clue what is down there. I tell him there are maggots; he seems indifferent. And that's what I just don't get. I would expect this is an alcoholic or addict. But this level of apathy in a sober person I've never seen before. Before I actually do vomit I ask him to roll back and go to call the surgeon.